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RESUMEN Antecedentes: la duodenopancreatectomía cefálica (DPC) con resección vascular venosa está indicada para el tratamiento del adenocarcinoma ductal y de tumores neuroendocrinos de páncreas, tanto por laparoscopia como por laparotomía. Objetivo: describir los resultados de una serie de pacientes operados de DPC con resección vascular venosa y comparar la morbimortalidad entre los abordados por laparoscopia y por laparotomía. Material y métodos: se realizó un estudio observacional, comparativo, retrospectivo de pacientes con DPC con resección vascular entre enero de 2022 y agosto de 2023. El abordaje laparoscópico fue determinado en menores de 80 años, invasión venosa tumoral igual a 180° o menor en la tomografía, buen performance status, y no haber realizado tratamiento neoadyuvante. Resultados: fueron realizadas 23 DPC con resección vascular venosa: 11 por laparoscopia y 12 por laparotomía. Las 11 realizadas por laparoscopia fueron resecciones laterales, y, en los 12 abordados por laparotomía, se realizó resección total de vena porta en 5 y en el resto, resección lateral. El tiempo de "clampeo" (pinzamiento) portal y la necesidad de transfusiones fue similar en ambos grupos. El estudio patológico reveló R0 en el 78,2% de los pacientes e invasión venosa en el 40.9%. La morbilidad con laparoscopia y con laparotomía consistió, respectivamente, en: fístula pancreática en 7 (4 y 3), vaciamiento gástrico retardado en 4 (1 y 4), fístula biliar en uno (1 y 0), neumonía en dos (1 y 1) e infección de herida en uno (0 y 1). La mortalidad fue de 8,6% por el fallecimiento de dos pacientes, uno en cada grupo. Conclusión: de acuerdo con los criterios empleados, la morbimortalidad de la DPC con resección vascular fue similar por laparoscopia y por laparotomía.

ABSTRACT Background: Cephalic pancreaticoduodenectomy (CPD) with venous resection is indicated for the treatment of ductal adenocarcinoma and neuroendocrine tumors of the pancreas, either through laparoscopy or laparotomy. Objective: The aim of this study was to describe the results of a series of patients undergoing CPD with venous vascular resection and compare morbidity and mortality between the laparoscopic approach and open surgery. Material and methods: We conducted a retrospective, comparative and observational study of patients who underwent CPD with venous vascular resection between January 2022 and July 2023. Criteria for laparoscopic surgery were age < 80 years, interface between tumor and vein of 180° of the circumference of the vessel wall or less on computed tomography, good performance status, and no previous neoadjuvant treatment. Results: A total of 23 CPD procedures with venous vascular resection were performed: 11 by laparoscopy and 12 by laparotomy. The 11 laparoscopic procedures were lateral resections, and in the 12 patients approached by laparotomy, 5 were total portal vein resections and 7 were lateral resections. Portal vein clamping time and need for transfusion was similar in both groups. The pathological examination reported R0 resections in 78.2% and venous invasion in 40.9%. The complications associated with laparoscopy and laparotomy were pancreatic fistula in 4 and 3 patients, respectively, delayed gastric emptying in 1 and 4 patients, respectively, biliary fistula in 1 and 0 patients, respectively, aspiration pneumonia i 1 and 1 patients, respectively and surgical site infection in 0 and 1 patients, respectively. Mortality was 8.6% (n =2), one in each group. Conclusion: According to the criteria used, the morbidity and mortality of CPD with vascular resection were similar for laparoscopy and laparotomy.

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BACKGROUND: Management of benign liver lesions (BLLs) is still an object of discussion. Frequently, patients receive multiple opinions about their diagnosis and treatment from physicians specialized in different areas, which can be opposite and controversial. This study aimed to understand patients' decision-making process in electing surgery and assess their satisfaction after resection for BLLs. METHODS: A 104-question survey was administered to 98 patients who had a resection for BLLs in 4 different hepatopancreatobiliary and transplant centers in Argentina. The first section included 64 questions regarding the initial discovery of the BLL, the decision-making process, and the understanding of the patient's feelings after surgery. The second section, 42 queries, referred to the quality of life. The patient's final diagnosis and outcome were correlated with the survey results using univariate analysis. RESULTS: Among 97 patients who had undergone liver resection for BLLs, 69 (70%) completed the survey. The median age was 51.71 years (range, 18-75), and 63% of the patients were females. Moreover, 21% of patients received conflicting information from different healthcare providers. Surgeons were the best to describe the BLL to the patient (63%), and 30% of patients obtained opinions from multiple surgeons. The respondents were quite or fully satisfied with their decision to have surgery (90%) and the decision-making process (91%). Only 59% of patients considered their lifestyle better after surgery, and 89% of patients would have retaken the same decision. CONCLUSION: Patients with resected BLLs are delighted with the decision to have surgery, regardless of the final diagnosis and outcome. The role of surgeons is crucial in the decision-making process.

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RESUMEN Antecedentes: la pancreatectomía izquierda laparoscópica es un procedimiento de alta complejidad que debe ser sistematizado para reducir complicaciones y tiempos quirúrgicos. Objetivo: Describir los resultados con una técnica sitematizada de esplenopancreatectomía laparoscópica. Material y métodos: se seleccionaron pacientes candidatos a realizar esplenopancreatecomía distal en el período comprendido entre 2007 y 2022. Se excluyeron pacientes con enfermedad sistémica. La técnica quirúrgica laparoscópica consiste en ligar los vasos cortos como primer paso, luego disecar y cortar la arteria esplénica, dejando la sección de la vena como último gesto quirúrgico. Esto evita la congestión venosa del bazo. Se analizaron variables preoperatorias, intraoperatorias y posoperatorias. Resultados: sobre un total de 155 pacientes, 90 fueron intervenidos por vía laparoscópica y 65 por vía convencional. El tiempo quirúrgico promedio fue 168 minutos. Cuando se analizó el tiempo quirúrgico en los abordajes laparoscópicos, se observó una disminución del tiempo a partir del caso número 30. La mortalidad fue del 1,12%. La incidencia de fístula pancreática total fue 41%. La necesitad de transfusión intraoperatoria ocurrió en el 10,7% de los pacientes y la tasa de conversión fue del 13,3%. Conclusión: la sistematización de la técnica de la pancreatectomía laparoscópica permite la reducción de los tiempos quirúrgicos, adquirir mayor seguridad en la disección y realizar procedimientos cada vez más complejos.

ABSTRACT Background: Laparoscopic left pancreatectomy is a high complexity procedure that should be systematized to reduce complications and operative time. Objective: To describe the results achieved with a systematized technique for laparoscopic pancreatectomy and splenectomy. Materials and methods: We selected patients who were candidates for distal pancreatectomy and splenectomy between 2007 and 2022. Patients with systemic diseases were excluded. The laparoscopic technique consists of ligating the short vessels as a first step, then dissecting and cutting the splenic artery, leaving the section of the vein as the last surgical gesture to avoid venous congestion of the spleen. Perioperative, intraoperative and postoperative variables were analyzed. Results: A total of 155 patients were analyzed, 90 underwent laparoscopy and 65 underwent conventional surgery. Mean operative time was 168 minutes The operative time in the laparoscopic approach decreased from case 30 onwards. Mortality rate was 1.12%. The incidence of pancreatic fistula was 41%. Need for intraoperative transfusion occurred in 10.7% of the patients and the conversion rate was 13.3%. Conclusion: The systematization of the technique of pancreatic laparoscopy is essential to reduce surgical times, ensure safe dissections and performe more complex procedures.

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Resumen Introducción: Si bien actualmente la 8a edición de la clasificación del AJCC para cáncer biliar, recomienda una linfadenectomía con 6 o más GL, su aplicación es escasa. Objetivo: Analizar la aplicabilidad y los resultados de la linfadenectomía en pacientes resecados con fines curativos por cáncer biliar. Materiales y Método: Análisis retrospectivo de pacientes operados por cáncer biliar de 2001 a 2018. Se analizaron variables perioperatorias referidas a la linfadenectomía (número de GL, GL+, morbilidad), comparando supervivencia en pacientes con < 6 y ≥ 6 GL resecados. Resultados: en 72 pacientes resecados por cáncer biliar (46 CaV, 26 CC), se realizaron 66 (91.7%) linfadenectomías N1. En 62.1% (n = 41) se obtuvieron < 6 GL y en el 37.9% (n = 25) ≥ 6 GL. El promedio de GL resecados fue de 5. En 16 (24,2%) linfadenectomías se hallaron GL+ sin diferencias entre ambos grupos. La morbimortalidad global fue de 30,3%, con una mortalidad del 4.5% sin diferencias. Con un seguimiento de 36.9 meses, la supervivencia a 5 años fue 43,7% (n = 17), 7 pacientes con ≥ 6 GL, y 10 pacientes con < 6 GL (p = NS). La supervivencia media en pacientes con GL+ fue 15 meses (6-34 meses). Conclusión: la linfadenectomía ocupa un rol primordial en la cirugía curativa del cáncer biliar, tanto para definir una estadificación y un pronóstico adecuados como para optimizar los resultados de la resección curativa en esta entidad. Su indicación debe ser sistemática con la obtención de un número adecuado de GL acorde a las recomendaciones actuales.

Introduction: Currently the 8th edition of the AJCC classification recommends the resection of 6 or more lymph nodes (LN) in gallbladder cancer and cholangiocarcinoma. However, its implementation is universally scarce. Aim: The goal is to analyze the applicability and results of lymphadenectomy in patients resected with curative purposes in biliary cancer. Materials and Method: a retrospective analysis of patients with biliary cancer (gallbladder carcinoma, intrahepatic and hilar cholangiocarcinoma) treated by curative resection from 2001 to 2018 was performed. Perioperative variables related to lymphadenectomy (LN number, LN positive, related morbidity) were analyzed, comparing survival in patients with < 6 and ≥ 6 resected LN. Results: 72 patients resected for biliary cancer (46 gallbladder cancer, 26 cholangiocarcinoma) were included with 66 (91.7%) N1 lymphadenectomies corresponding to the hepatoduodenal ligament nodes performed. In 62.1% (n = 41) < 6 LN and in 37.9% (n = 25) ≥ 6 LN were resected. Average LN count was 5. In 16 (24.2%) patients positive LN were found, 7 in the group with ≥ 6 LN (28%) vs. 9 in the group with < 6 LN (22%) (p = NS). Overall morbimortality was 30.3% (n = 20). Average follow-up was 36.9 months. Survival at 5 years was 43.7% (n = 17), 7 patients with lymphadenectomy ≥ 6 LN, and 10 patients with < 6 LN (p = NS). Survival mean in patients who had positive LN was 15 months. Conclusión: Lymphadenectomy has a primary role in the radical resection with curative intention for biliary cancer. Systematic indication of lymphadenectomy should be prioritized, with the achievement of an adequately number of LN according to the actual recommendations. Lymphadenectomy is crucial for an adequate staging and prognosis, as well as to optimize the results of curative resection in this entity.

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Resumen La pandemia COVID-19 declarada en marzo del 2020, ha generado preocupación mundial por su efecto en la salud de la población y el potencial colapso sanitario. La estrategia de "aplanar la curva" mediante el distanciamiento social permitió adaptar los recursos del sistema de salud a pacientes con COVID-19, pero no se pudo prever su repercusión en otras áreas de la salud. El objetivo de este trabajo fue analizar las consecuencias de la pandemia sobre el trasplante hepático en general y por hepatocarcinoma (HCC). Fueron realizados los siguientes estudios: a) un análisis retrospectivo utilizando datos del CRESI/INCUCAI para comparar ingreso en lista de espera, mortalidad en lista, donación y trasplante hepático desde 20/03 a 15/08, 2019 e igual periodo de 2020, y b) una encuesta a los centros de trasplante de mayor actividad trasplantológica para valorar el efecto de las medidas tomadas en diferentes situaciones institucionales y regionales. El primer análisis evidenció una disminución del 55% de los trasplantes hepáticos, con una reducción similar en la donación y en el ingreso a lista de espera hepática; mientras que el trasplante por HCC ascendió de 10% en 2019 a 22% en 2020. El segundo análisis, mostró que la tasa de ocupación de camas por pacientes COVID-19/semana fue variable: de 0.4% al 42.0%. El número de cirugías, hepato-bilio-pancreática, resección de HCC y trasplante hepático, se redujeron en 47%, 49%, 31% y 36% respectivamente. La reducción de la actividad trasplantológica afectó mayormente los centros con alta ocupación por COVID-19. El impacto final a largo plazo deberá evaluarse.

Abstract The COVID-19 pandemic declared in March 2020, has generated worldwide concern due to its effect on the health of the population and the potential health collapse. The strategy of "flattening the curve" through social distancing made it possible to adapt the resources of the health system to patients with COVID-19, but results in other areas of health could not be predicted. The objective of this work was to analyze the consequences of the pandemic on liver transplantation in general and for hepatocarcinoma (HCC). The following studies were carried out: a) a retrospective analysis using data from the CRESI / INCUCAI to compare admission to the waiting list, mortality on the list, donation and liver transplantation from 03/20 to 08/15, 2019 and the same period in 2020, and b) a survey of the transplant centers with the highest transplant activity to assess the effect of the measures taken in different institutional and regional situations. The first analysis showed a 55% decrease in liver transplants, with a similar reduction in donation and admission to the liver waiting list; while HCC transplantation rose from 10% in 2019 to 22% in 2020. The second analysis showed that the occupancy rate of beds by COVID-19 patients / week was variable: from 0.4% to 42.0%. The number of surgeries, hepato-bilio-pancreatic, resection of HCC and liver transplantation, were reduced by 47%, 49%, 31% and 36% respectively. The reduction in transplant activity mainly affected centers with high occupancy due to COVID-19. The final long-term outcome will need to be assessed.

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RESUMEN Antecedentes: la pancreatitis aguda posduodenopancreatectomía cefálica inmediata es una complica ción cuya frecuencia puede llegar al 55% y condiciona la aparición de fístula pancreática. Objetivo: describir el manejo de 3 pacientes que presentaron pancreatitis aguda posduodenopancrea tectomía con complicaciones locales y realizar una revisión de la literatura. Material y métodos: se revisó una base de datos prospectiva de resecciones pancreáticas. Se identifi caron los pacientes con diagnóstico de pancreatitis aguda con lesiones locales posterior a la realización de duodenopancreatectomía. Se definió fístula pancreática de acuerdo con la clasificación del ISGPF y pancreatitis como la elevación de la amilasa o lipasa tres veces por encima del máximo valor sérico normal en asociación con dolor abdominal o confirmación radiológica. Resultados: entre 2008 y 2019 los autores realizaron 260 duodenopancreatectomías. Tres pacientes presentaron pancreatitis posoperatoria con complicaciones locales. Conclusiones: la pancreatitis aguda posoperatoria es una complicación de una frecuencia elevada. La mayoría de ellas se resuelven en forma espontánea. Pocos pacientes presentan complicaciones locales que pueden requerir tratamiento percutáneo o quirúrgico, predisponiendo al desarrollo de fístulas a veces de difícil manejo. No hay forma de prevenir la aparición de la fístula pancreática. El tratamiento de las complicaciones locales se realizará de acuerdo con su aparición y repercusión, pudiendo requerir desde la colocación de un drenaje percutáneo hasta la pancreatectomía total.

ABSTRACT Background: The incidence of acute pancreatitis immediately after cephalic pancreaticoduodenec tomy is up to 55% and is associated with the development of pancreatic fistula. Objective: The aim of this study is to report three cases of acute pancreatitis after pancreaticoduode nectomy with local complications with a review of the literature. Material and methods: The information about pancreatic resections was retrieved from a prospective database. Patients with diagnosis acute pancreatitis with local lesions immediately after pancreatico duodenectomy were identified. Pancreatic fistula was defined according to the International Study Group on Pancreatic Fistula (ISGPF) Definition and pancreatitis was defined as serum amylase or lipase >3x upper limit of normal associated with abdominal pain or imaging criteria. Results: A total of 260 pancreaticoduodenectomies were performed between 2008 and 2019. Three patients developed postoperative acute pancreatitis with local complications. Conclusions: Postoperative acute pancreatitis is a common complication that solves spontaneously in most cases. Few patients present local complications that may require percutaneous or surgical treatment, which may predispose to the development of fistulas that are sometimes difficult to mana ge. There is no way to prevent pancreatic fistulas. Local complications will be treated according to their occurrence and impact, and may require a variety of procedures, ranging from percutaneous drainage to total pancreatectomy.

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The COVID-19 pandemic declared in March 2020, has generated worldwide concern due to its effect on the health of the population and the potential health collapse. The strategy of "flattening the curve" through social distancing made it possible to adapt the resources of the health system to patients with COVID-19, but results in other areas of health could not be predicted. The objective of this work was to analyze the consequences of the pandemic on liver transplantation in general and for hepatocarcinoma (HCC). The following studies were carried out: a) a retrospective analysis using data from the CRESI / INCUCAI to compare admission to the waiting list, mortality on the list, donation and liver transplantation from 03/20 to 08/15, 2019 and the same period in 2020, and b) a survey of the transplant centers with the highest transplant activity to assess the effect of the measures taken in different institutional and regional situations. The first analysis showed a 55% decrease in liver transplants, with a similar reduction in donation and admission to the liver waiting list; while HCC transplantation rose from 10% in 2019 to 22% in 2020. The second analysis showed that the occupancy rate of beds by COVID-19 patients / week was variable: from 0.4% to 42.0%. The number of surgeries, hepato-bilio-pancreatic, resection of HCC and liver transplantation, were reduced by 47%, 49%, 31% and 36% respectively. The reduction in transplant activity mainly affected centers with high occupancy due to COVID-19. The final long-term outcome will need to be assessed.

La pandemia COVID-19 declarada en marzo del 2020, ha generado preocupación mundial por su efecto en la salud de la población y el potencial colapso sanitario. La estrategia de "aplanar la curva" mediante el distanciamiento social permitió adaptar los recursos del sistema de salud a pacientes con COVID-19, pero no se pudo prever su repercusión en otras áreas de la salud. El objetivo de este trabajo fue analizar las consecuencias de la pandemia sobre el trasplante hepático en general y por hepatocarcinoma (HCC). Fueron realizados los siguientes estudios: a) un análisis retrospectivo utilizando datos del CRESI/INCUCAI para comparar ingreso en lista de espera, mortalidad en lista, donación y trasplante hepático desde 20/03 a 15/08, 2019 e igual periodo de 2020, y b) una encuesta a los centros de trasplante de mayor actividad trasplantológica para valorar el efecto de las medidas tomadas en diferentes situaciones institucionales y regionales. El primer análisis evidenció una disminución del 55% de los trasplantes hepáticos, con una reducción similar en la donación y en el ingreso a lista de espera hepática; mientras que el trasplante por HCC ascendió de 10% en 2019 a 22% en 2020. El segundo análisis, mostró que la tasa de ocupación de camas por pacientes COVID-19/semana fue variable: de 0.4% al 42.0%. El número de cirugías, hepato-bilio-pancreática, resección de HCC y trasplante hepático, se redujeron en 47%, 49%, 31% y 36% respectivamente. La reducción de la actividad trasplantológica afectó mayormente los centros con alta ocupación por COVID-19. El impacto final a largo plazo deberá evaluarse.

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BACKGROUND: Residual disease (RD) has been described as one of the most relevant prognostic factors after radical surgical resection for incidental gallbladder cancer (IGC). The purpose of the present study was to analyze patterns of RD and determinant prognostic factors in patients undergoing re-resection for IGC. METHODS: Patients undergoing re-exploration due to IGC between 1990 and 2014 were identified in two referral centers from different South-American countries. Patients submitted to a radical definitive operation were included in the study. Demographics and tumor-treated related variables were analyzed in correlation with RD and survival. The site of RD, local (gallbladder bed) or regional (lymph nodes and bile duct) was correlated with disease-specific survival (DSS). RESULTS: Of 265 patients with IGC submitted to surgery, 168 underwent a radical re-resection and RD was found in 58 (34.5%). Demographic, clinical and surgical variables were compared between both centers showing differences in type of resection, laparoscopic approach, T stages and disease stage. Location of RD was regional in 34 (20.2%) and local in 24 (14.3%), and no residual disease was found in 110 (65.5%) patients. T stage (T1b = 20%, T2 = 23.8%, T3 = 71.7%, p < 0.001) and disease stage (p < 0.001) were independent predictors of RD. Finding RD at any location reduced the DSS in comparison with non-RD patients (19.6 months vs. 62.7 months p < 0.001). No differences in DSS according to the location of RD were found, and all anatomic sites were equally poor (p = 0.27). RD at any site predicted DSS (p < 0.001), independently of all other IGC variables. CONCLUSIONS: IGC presented similar clinical parameters in two different countries of South America. RD was demonstrated as the most critical prognostic variable in patients with IGC treated by a radical resection. The presence of RD was associated with poor outcome, independently of any anatomic location. Future studies incorporating neoadjuvant chemotherapy in the treatment of patients with prognostic factors for RD are required to improve survival in this entity.

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Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignant tumor and its incidence is increasing over the world. At present times, radical liver resection is still the most effective treatment for ICC patients to achieve long term survival. Pathological lymph node metastases (LMN), found in 15% to 45% of the patients, have been recognized as an extremely poor prognostic risk factor, even if curative resection is performed. So, considering this issue, it acquires relevance to determine the validity of surgical resection for LNM cases that are diagnosed in the preoperative setting, or whether a routine lymphadenectomy should be performed systematically in all hepatectomies for ICC. The role of routine lymphadenectomy in the surgical treatment of ICC remains controversial, with some centers considering it standard whereas other surgeons perform lymphadenectomy only as a selective indication. Recently, a growing widespread adoption of lymphadenectomy was demonstrated that nearly doubled its commonly reported execution rate. The newly updated eight edition of the American Joint Committee on Cancer (AJCC) staging system now recommends that six nodes need to be analyzed to stage patients with ICC. In this review, we analyzed and summarized some anatomic considerations of the lymphatic anatomy of the liver and the current knowledge and potential advantages of performing a routine lymphadenectomy in patients with ICC, especially looking at pathological staging, prognosis, prevention of local recurrence and outcome. New areas like lymphadenectomy in cirrhotic patients and laparoscopic lymphadenectomy are also discussed.

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Background : Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients with these tumors. Aim : In this module, was contextualized the clinical situations and parameterized epidemiological data and results of the various treatment modalities established. Method: Was realized deep discussion on detecting and staging metastatic colorectal cancer, as well as employment of imaging methods in the evaluation of response to instituted systemic therapy. Results : The next step was based on the definition of which patients would have their metastases considered resectable and how to expand the amount of patients elegible for modalities with curative intent. Conclusion : Were presented clinical, pathological and molecular prognostic factors, validated to be taken into account in clinical practice.

Racional : As metástases hepáticas de câncer colorretal são evento frequente e potencialmente fatal na evolução de pacientes com estas neoplasias. Objetivo : Neste módulo procurou-se contextualizar esta situação clínica, bem como parametrizar dados epidemiológicos e de resultados das diversas modalidades de tratamento estabelecidas. Método : Foi realizada discussão sobre como detectar e estadiar o câncer colorretal metastático, bem como o emprego dos métodos de imagem na avaliação de resposta ao tratamento sistêmico instituído. Resultado : Fundamentou na definição de quais pacientes teriam suas metástases consideradas ressecáveis e de como se poderia ampliar a gama de pacientes submetidos às modalidades de tratamento ditas de intuito curativo. Conclusão : Foram apresentados os fatores prognósticos clínicos, patológicos e moleculares com validação para serem levados em consideração na prática clínica.

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